Kidney transplantation is the optimal treatment modality for renal replacement therapy in patients with end-stage renal disease. The increased age of both donors and recipients has made kidney implantation more demanding. Additionally, peripheral vascular disease is on the rise worldwide, leading to challenges in kidney transplantation and worse long-term outcomes, including reduced graft and/or patient survival. Despite these challenges, dialytic treatment yields even worse outcomes and kidney transplantation remains the preferred approach even in patients with complex vascular issues. Some of the aggravating factors include calcified arteries, the presence of aortoiliac or endovascular prostheses, and the need for retransplantation (especially third and fourth transplantations). Prior to transplantation, thorough imaging methods, including invasive ones, must be used for all patients. Before the operation it is crucial to select the appropriate implantation site and inform patients about potential difficulties and complications, including the possibility of intraoperative withdrawal of transplantation. Possible implantation sites include vascular prostheses, more proximal blood vessels extending up to the aorta and inferior vena cava. In some cases, orthotopic kidney transplantation serves as a good alternative. However, the number of complications tends to be higher in this patient population compared to the standard population. In summary, kidney transplantation in these patients represents a challenging surgical procedure with increased morbidity and mortality, decreased survival of the graft and patients, necessitating an experienced surgical team.